• Nathan Riley, MD

On My Departure From Hospital-Based Birth: A Reflection

Today is my final shift as an obstetrician.

This journey began back in college, when medicine still had its idyllic pull. My wannabe doctor friends and I were determined to join the ranks of physicians like those we saw in the Normal Rockwell paintings, where physicians built practices founded upon relationship building. But this was no easy task. We maintained absurdly high GPAs on 20-credit course loads, and our curricula vitae were dotted with projects like graduate level laboratory work, teaching physics at Carnegie Mellon, competing in triathlon, and volunteering any remaining time to the underserved of our steel city. Entire summers were dedicated to tasks that served as fine polish for our applications, which, for me, included the foundation of a successful international non-profit serving Malawi's poorest and sickest AIDS patients through the efforts of community-based organizations. It was all-consuming, and sure, we partied to let off steam, but we were simultaneously among the most regimented students at the University of Pittsburgh.

Medical school was only available to the few of us that achieved the highest honors and admissions scores. Medical school was a different beast entirely, and it took academic rigor to a new level. Imagine covering the material of a full academic textbook every 2-4 weeks. This is no exaggeration. There is so much information packed into the four years of medical school that it's a wonder that we don't begin to specialize sooner: physiology, pathology, physical exams, imaging, laboratory analysis, writing notes, communicating plans, the list goes on. I managed to find time for romance here and there, and I even reconnected with my now amazingly supportive wife towards the end, but sleep and self-care had largely fallen by the wayside. Nevertheless, I'm still glaring at nearly $500,000 of debt to prove that I survived. The title of "doctor" was in-hand; I just needed to choose a specialty.

My mind was a sponge, and, at the beginning of each clinical rotation, I found the individual specialty intriguing as a possible career path, but none captivated me more than obstetrics. The first couple births that I attended were purely magic. I was able to remove myself from the learned pathology of the process and soak in the infallible beauty of human being. Obstetrics was something that I could get behind, so I did.

It would seem to the innocent bystander that I had it made: I had become a physician, met my future wife, and found a specialty that I loved. So what happened?

Well, residency happened.

The next leveling up in a physician's journey is the ultra-competitive residency application process. If you manage to match into an accredited program - and many don't - you are rewarded with the Herculean task of work weeks ranging in commitment up to 120 hours. Encouragement came from more senior physicians in the form of anecdotes about their 160-hour work weeks, not acknowledging - whether consciously or unconsciously - that the required health record documentation, administrative bullshit, and sheer volume of new medical knowledge that needs to be acquired in four years of contemporary OB/GYN residency demands that we sleep less and completely confiscate our social lives so that we have time to study medical journals outside of the confines of the regular 120-hour work weeks.

This work volume understandly came with limitations on allotted time for sleep, and 70% of this training was in the operating room, where we were expected to forgo eating until a 30-minute window permitted the scarfing of as many calories as possible between surgeries. One of my attendings even told me that "your wife needs to understand that she comes second". It's no wonder that a quarter of medical trainees experience a major depressive episode during their training or that physician suicide is on the rise.

It was dehumanizing. This is where the magic began to fade, and it didn't get much better after residency.

The life of a hospital-based OB/GYN is misery. Phone calls throughout the night to fix problems that we created through attempts to induce or intensify birth surges are a prime example of how our priorities have become thoroughly ass-backwards.

The tired nurse calls the tired physician who becomes increasingly more annoyed with the tired nurse who reflects this annoyance and the cycle continues.

Off shift, and when you're not racing through a packed clinic, OB/GYNs lose precious family time fielding calls from administrators or coders that want to schedule meetings with you in order to shore up your documentation in order to squeeze every last dollar out of the patient's insurance company, seemingly just so that they can advertise how great their profit margins are to all of their tired staff by way of a half-assed taco party that will take place, we're told, "sometime this spring". This is the life of most physicians. Family third, patients second, the business of medicine - a part of which you are a small cog - first. Romantic, isn't it?

I attended a birth here in the hospital recently where there were 12 people in the room, only one of whom was birthing. This included three family members. Two labor and delivery nurses. One surgical tech. Three nurses from the neonatology team ("we come for all deliveries", they told me). One nursing student. And myself. Granted, each of these people had a well-defined task, which they were performing well, but what does a birthing woman really need? Does she need all of the cables, lines, noise, and distraction? Does she need the bright lights? Does she need stirrups and people yelling at her to push? Does the baby need a diaper right now? Does the cord need to be clamped immediately? Does a newborn exam have to take place at this second? Does it need a bath? Is the weight and length that critical? Gently asking the crowd to disperse while the patient is going through what I can only imagine is one of the most exciting and simultaneously frightening moments of her life ultimately just results in the nurses thinking I'm a dickhead. Fair enough.

A less passive aggressive question might be: What in the actual fuck are you all doing here anyways? Are all of these tasks needed to keep a pregnant woman safe? The fact that our maternal mortality data pales in comparison to many other developed countries makes this question rhetorical in my eyes.

Indeed, physicians are the cream that rise to the top, and they are more dedicated than any other health care professionals to the task of caring for the sick. This is an understated truth. The amount of sacrifice that we commit to being here is unparalleled. But the model I am describing is a far cry from those Norman Rockwell paintings, where a smiling physician is rubbing the boo-boos of children and attending to the medical needs of the elderly. Who knows? Maybe Rockwell didn't have a clue and was merely illustrating what medicine could be. Or maybe the magic that I felt while attending my first few births in medical school was merely an illusion.

The decision to leave hospital-based obstetrics has been in development since I began residency. It has nothing to do with an unwillingness on my part to accept that hospitals can provide a safety net to the rare individuals who need medical help in pregnancy. Of course, if my wife needed emergent surgery to save her life or our baby required medical attention to stave off catastrophe, I'd be right on board. But that's not most pregnancies and certainly not most newborns. My disillusionment stems from the realization that the hospital treats the entire life cycle - the same process that I found magical back in medical school - as pathology, and, as a result, it has been stripped of humanity.

Many of my OB/GYN colleagues have asked, "How could you leave a field to which you dedicated so much of your life?" Thinking back on my six years of practice within the field, it is sad for me that things didn't work out because, early in my training, I admired so deeply the obstetricians and gynecologists that I worked with, not to mention the numerous labor and delivery nurses. But having been stripped of our own humanity through training and practice, it's impossible to continue on this path. Through my work in palliative medicine, it's no longer possible for me to understand the medical question without first getting to know the person. But outside of palliative medicine, physicians aren't rewarded for getting to know the patient. We are rewarded for maximizing the hospital's profits. And we otherwise only have time to care about getting the job done quickly so that we can be home in time for dinner for once.

Furthermore, the unique medical-legal debacle in the United States has set precedence for holding physician licenses at gunpoint.

Remember that movie, Sully? Where Tom Hanks lands a passenger airplane on the Hudson River out of desperation after full engine failure? The jury held him accountable for his "mistake" given several other pilots eventually figured out the precise sequence of procedures that could have enabled him to turn the plane around to land at an airport. Yet Sully argues, correctly, that these simulations don't take into account the time required for human decision-making. In other words, hindsight is always 20/20. Sully was a true professional, and he made a split decision that saved lives. Many OB/GYNs have lost their privileges and licenses for no less, doing what they thought was best for the patient at that moment in time. Isn't this why we pay physicians decent salaries, because they have skills that many others haven't practiced? Don't we want physicians to feel safe putting their expertise into action in the event of an emergency?

Simulations and expert testimony shouldn't be able to touch that, but, alas, precedence has been set: prosecuting attorneys and the clients that they represent have stripped the human element of medicine away from those doctors who have dedicated their lives to this practice since age 18, and doctors, in return (and in their own defense) have stripped the human element away from birth. All of those helpers in the delivery room are happily paid for by the hospital in order to check as many nebulous boxes as possible under the guise of "safety", which, by any other interpretation, could actually be seen as lawsuit avoidance.

Deep down, we know that more medicine doesn't help most birth. Most birth happens whether or not I'm there to "deliver" the baby, and our collective OB/GYN gestalt tells us that the more that we do, the worse the outcome, yet we are held accountable by non-clinician hospital administrators and prosecution attorneys to do innumerable, unhelpful tasks to support pregnancy and birth. The birth magic that we all first experienced was lost long ago, and this is why many OB/GYNs prefer to focus their time on gynecology.

This is and always has been the state of hospital-based obstetrics. The woman, the person to whom we have set forth to care, has fallen by the wayside to our overemphasis on defense from lawsuits, business administration, and comforts of the "delivery team", such as the dorsal lithotomy position in the 2nd stage of birth. This transition, which began hundreds of years ago, is a big fuck you to a most precious moment that sustains our species. A moment that is as at least as important as death. These events make us who we are, yet the medical system has failed to uphold the magic.

I'll be giving up the practice, but I'll maintain my currency in the medicine. I will continue reading, interpreting and presenting the literature. I may even find my way back into clinical practice, but I won't be working in a hospital, where women have been trained to fear birth. I'll be striving to support - whether clinically or otherwise - the birth workers and other women who see birth as a rite of passage, as a natural expression of feminine power, as a normal physiologic process. As a part of being human. I'll be doing my part to address the inequalities in medicine and to bridge the racial divide that has led women of color to fear hospitals. You'll find me breaking bread with the birth educators, doulas, witches, midwives, nurses, and other physicians who guide their patients to safety without failing to appreciate the beauty and majesty displayed by a birthing human.

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